Methods and compositions for treating inflammatory bowel disease

ABSTRACT

The present invention provides a method and composition of medications use to treat inflammatory bowel disease. The invention further provides combinations of anti-atypical mycobacterial agents effective against the atypical mycobacterial strains. It also provides a method of potentiating the anti-atypical mycobacterial agents effective agents in treatment of inflammatory bowel disease by immunising patients with extracts of non-pathogenic mycobacteria.

TECHNICAL FIELD

The invention relates to compositions and methods for the treatment ofinflammatory bowel disease, such as Crohn's disease.

BACKGROUND OF THE INVENTION

Inflammatory bowel disease (IBD) is a disorder of unknown aetiologycharacterised typically by diarrhoea, cramping, abdominal pains, weightloss and rectal bleeding. It encompasses such disorders as Crohn'sdisease, ulcerative colitis, indeterminate colitis, microscopic colitisand collagenous colitis. Its cause is unknown. However, in the pastthere has been some evidence that Mycobacterium paratuberculosis (Mp)and perhaps its various sub-strains, may play an infective role byentering the cells which make up the bowel wall. The source of thisbacterium is unclear but may reside in other animals such as sheep,cattle, rabbits, as well as other humans. It may be transmitted topeople perhaps via milk, contaminated water supplies, poorly cookedmeat, etc. Although there has been long-standing controversy about theinvolvement of Mp in causation of Crohn's disease, recent applicationsof PCR usage are beginning to confirm that most Crohn's cases are indeedinfected with this organism which is likely to be the causal infectiveagent. In the past, therapy directed at the eradication of Mp by usingcombined anti-TB drugs eg INH, pyrazinamide, streptomycin, ethambutol,rifampicin and PAS have been generally of little help to patients. Inother words, although transient improvements in a proportion of patientsdid occur, no patient was cured. In fact, even if Mp had been the causeof this disease there was no effective therapy available for Mp since itwas an “atypical mycobacterium” and for atypical mycobacteria there wasno known therapy. Furthermore, since Mycobacterium paratuberculosis hasa long division time multiple antimicrobial drugs are required to thetreat the infection which has to be carried out for a long period oftime—akin to the treatment used in the therapy of Mycobacteriumtuberculosis. Furthermore, Mycobacterium tuberculosis therapy with thecurrent drugs results in resistant strains forming. Such resistantstrains do not become eradicated with known antimicrobial agents. Hence,there is no known effective cure for resistant TB.

Accordingly, there is a need for an effective treatment of inflammatorybowel disease, and in particular Crohn's disease. It is an object ofthis invention to provide such a treatment.

Surprisingly, the present inventor has discovered that the metabolism ofthe mycobacteria believed to be responsible for the symptoms ofinflammatory bowel disorders may be inhibited long enough to cure theinfection and thus relieve the symptoms, by administering to the patienta combination of anti-atypical mycobacterial agents and/or an immunisingamount of a mycobacterial product.

SUMMARY OF THE INVENTION

The present invention provides a method and composition of medicationsused to treat inflammatory bowel disease including Crohn's disease andcolitis. The methods of the invention result in a cure of the infectionand reversal of the clinical condition. The invention further providescombinations of anti-atypical mycobacterial agents effective against theatypical mycobacterial strains. It also provides a method ofpotentiating the anti-atypical mycobacterial agents in treatment ofinflammatory bowel disease by immunising patients with extracts ofnon-pathogenic mycobacteria.

Thus, in a first embodiment, the invention provides a composition forthe treatment of inflammatory bowel disease including three or moreanti-atypical mycobacterial agents.

In a second embodiment, the invention provides a method for thetreatment of inflammatory bowel disease including administering to apatient in need of said treatment an effective amount of at least threeanti-atypical mycobacterial agents.

In a third embodiment, the invention provides a method for the treatmentof inflammatory bowel disease including administering to a patient inneed of said treatment an effective amount of at least threeanti-atypical mycobacterial agents and immunising the patient with animmunising amount of a mycobacterial extract or product.

In a fourth embodiment, the invention provides a method for thetreatment of inflammatory bowel disease including administering to apatient in need of said treatment an immunising amount of amycobacterial extract or product.

In further embodiments, the invention provides (a) the use of acomposition comprising three or more anti-atypical mycobacterial agentsfor the manufacture of a medicament for the treatment of inflammatorybowel disease; (b) the use of a composition including at least threeanti-atypical mycobacterial agents and a mycobacterial extract orproduct for the manufacture of a medicament for the treatment ofinflammatory bowel disease; and (c) the use of a mycobacterial extractor product for the manufacture of a medicament for the treatment ofinflammatory bowel disease.

DESCRIPTION OF THE INVENTION

This invention discloses a method of use and compositions useful in thetreatment of Crohn's disease and colitis and of other inflammatory boweldiseases using various combinations of anti-atypical mycobacterialdrugs.

In the composition of the first embodiment of the invention, or themethods of the second or third embodiments, valid combinations ofanti-atypical mycobacterial agents include triple (three drugs)groupings of anti-atypical mycobacterial agents, or indeed largercombinations for exceptional situations, eg where resistant strainsemerge. Four, five and even six drug combinations may be required inpatients with resistant Mycobacterium paratuberculosis strains. Suitableanti-atypical mycobacterial agents include, but are not limited to,clarithromycin, rifabutin, rifampicin, rifapentene, azithromycin,roxithromycin, cefazoline, minocyclin, streptomycin, amikacin,clofazimine, ethambutol, ofloxacin, sparfloxacin, levofloxacin,pefloxacin, grepafloxacin, trovafioxacin, norfloxicin, enoxacin,lomefloxacin, ciprofloxacin and oxazolidinone. These may be co-used withone or more 5-aminosalicylic acid compounds or 4-aminosalicylic acidcompounds such as mesalazine, olsalazine, salazopyrin or para-aminosalicylic acid. Typically, at least one of the anti-atypicalmycobacterial agents is rifabutin or clarithromycin. More typically, thecomposition of the first embodiment includes rifabutin, clarithromycinand clofazimine. Similarly, the methods of the second and thirdembodiments usually involve the administration to the patient of aneffective amount of a combination of rifabutin, clarithromycin, andclofazimine.

Surprisingly, the combination of three or more anti-atypicalmycobacterial agents exhibits a substantially greater effect againstinflammatory bowel disease than would have been expected from eachanti-atypical mycobacterial agent alone.

Typically, the composition of the present invention may include between10-500 mg of each of three or more anti-atypical mycobacterial agents.More typically, the composition of the present invention may includebetween 10-250 mg of each of three or more anti-atypical mycobacterialagents. Even more typically, the composition of the present inventionmay include rifabutin present at between 50-250 mg, more typically,approximately 15 mg, clarithromycin at between 200-30 mg, moretypically, approximately 250 mg, and clofazimine at between 10-150 mg,more typically, approximately 50 mg. Further, other anti-atypicalmycobacterial agents may be present in amounts in accordance with knowndosages.

Typically, the composition of the present invention may be available inthe form of a tablet containing each of three or more anti-atypicalmycobacterial agents present in a compressed powdered form.Alternatively, the composition of the present invention may be availablein the form of a tablet capsule containing one or more of theanti-atypical mycobacterial agents in a microencapsulated form. Asanother possibility, the composition of the present invention may beavailable in the form of a tablet capsule containing one of the three ormore anti-atypical mycobacterial agents present in a powdered form, andthe remaining anti-atypical mycobacterial agents present in amicroencapsulated form. As a further possibility, the composition of thepresent invention may be available in the form of a tablet capsulecontaining each of three or more anti-atypical mycobacterial agentspresent in a microgranulated form. In even further possibilities, thecomposition of the present invention may be available in the form of atablet(s) containing one or more of the anti-atypical mycobacterialagents within a capsule, a capsule(s) containing one or more of theanti-atypical mycobacterial agents within a tablet, a capsule(s)containing one or more of the anti-atypical mycobacterial agents withinan outer capsule containing the other anti-atypical mycobacterialagents, or any combination of the above.

In a preferred form, the composition of the invention consists of aninner capsule containing rifabutin, within an outer capsule containingclarithromycin and clofazimine, wherein clarithromycin and clofaziminemay be present in powdered, microencapsulated, or microgranulated forms.

Typically, the methods of the present invention may be carried out byadministration of one or more tablets/capsules containing each of threeor more anti-atypical mycobacterial agents as described in theimmediately preceding paragraph, or through the administration of eachof three or more anti-atypical mycobacterial agents separately.

In the method of the fourth embodiment a patient previously not treatedor on current anti-inflammatory therapies is treated by immunisationwith a mycobacterial extract or product (living or dead, or itsextracted wall and DNA components) as an immunising agent to stimulateleucocytes in the immunised patient. Such immunising agents may beextracts or products from known, non-pathogenic mycobacteria such as M.vaccae or M. phlei. As used herein, the expression “mycobacterialextract or product” means whole killed mycobacteria or mycobacterialextract, with or without adjuvants. An example of a suitablemycobacterial product or extract is Regressin, available from Bionicheof London, Ontario, Canada.

The mycobacterial product may be used to recurrently iminunise thepatient using the product as an immunostimulant. The mycobacterialproduct can be administered via any of several routes, such as oral,intravenous, intramuscular or subcutaneous. Such immunisations can ridthe patient of the Mp infection and have the ability to cure the diseaseor place the patient into a prolonged remission. Administration of themycobacterial product or extract is typically from weekly to monthly,but may be more or less frequent. An appropriate treatment regime may bearrived at readily by a medical practitioner in any particular case,given the teaching herein.

A preferred therapy with Mycobacterium phlei extract (eg Regressin)includes a weekly immunisation program, increasing the dosage by 50 μgof the extract every week until the patient develops fever, rigors andnausea. The dose is then dropped by 50 μg to the lower level and thepatient continues maintenance immunisation on a monthly basis. Thetreatment can last from 6 weeks up to a monthly immunisation program of2 years or more.

In another form of therapy standard anti-inflammatory therapy can becombined with recurrent Regressin immunisation.

In the method of the third embodiment, at least three anti-atypicalmycobacterial agents are combined with use of a mycobacterial extract orproduct as an immunising agent. The mycobacterial extract or product foruse in the method of the third embodiment may be a mycobacterial extractor product as described above with reference to the third embodiment.For example, rifabutin may be combined with clarithromycin andclofazimine in the therapy and further combined with an immunisingprotocol using M. phlei extract (e.g. Regressin).

In the methods of the invention, the anti-atypical mycobacterial agentsare usually used continuously over a period of 3 to 36 months. Dosagesof the anti-atypical mycobacterial agents are generally in accordancewith known dosage ranges For example, the typical dosage ofclarithromycin is from 250 mg to 1.5 g per day, more typically about 750mg per day; the typical dosage of rifabutin is from 150 mg to 750 mg perday, more typically about 450 mg per day, the typical dosage ofclofazimine is from about 1 mg/kg to about 6 mg/kg, more typically about2 mg/kg; the typical dosage of ethambutol is up to about 15 mg/kg; andthe typical dosage of azithromycin is from 250 mg to 1000 mg per day,more typically about 500 mg per day.

The inflammatory process may be monitored by colonoscopy and biopsy, aswell as various blood parameters, during the course of treatment inaccordance with the invention.

Preferably, the method of the third embodiment consists of a 24 monthtreatment daily of clarithromycin combined with rifabutin andclofazimine, at dosages as described above. In a more preferred method,the patient will also be recurrently immunised at intervals using amycobacterial extract of M. phlei (Regressin). This can be given orally,intravenously, subcutaneously, or in combinations of the above. Doses ofthe mycobacterial extract can be given in any frequency ranging from 25μg to 500 μg, more typically, 50 μg to 500 μg. However, weekly tomonthly, typically weekly or monthly, is usually adequate to maintainimmuno-stimulation.

The methods of the present invention can also be combined with one ormore milder anti-TB agents such as salazopyrin, olsalazine ormesalazine, as well as other less known aminosalicylic acids. The4-aminosalicyclic acids or 5-aminosalicylic acids can be combined withany three or more of the anti-atypical mycobacterial agents mentionedabove. Dosages of these agents are generally known. For example thetypical dosage range for salazopyrin is in the range of from about 500mg to 4 g per day; and for olsalazine or mesalazine from about 500 mg toabout 3 g per day. Thus, the composition of the first embodiment mayfurther include an agent effective against tuberculosis. Similarly, themethod of the second or third embodiments may further includeadministering an effective amount of an agent effective againsttuberculosis.

Compositions for administration of the invention may be prepared bymeans known in the art for the preparation of compositions (such as inthe art of pharmaceutical compositions) including blending, grinding,homogenising, suspending, dissolving, emulsifying, dispersing and whereappropriate, mixing of the anti-atypical mycobacterial agent togetherwith selected excipients, diluents, carriers and adjuvants.

For oral administration, the pharmaceutical composition may be in theform of tablets, lozenges, pills, troches, capsules, elixirs, powders,including lyophilised powders, solutions, granules, suspensions,emulsions, syrups and tinctures. Slow-release, or delayed-release, formsmay also be prepared, for example in the form of coated particles,multi-layer tablets or microgranules.

Solid forms for oral administration may contain pharmaceuticallyacceptable binders, sweeteners, disuinegrating agents, diluents,flavourings, coating agents, preservatives, lubricants and/or time delayagents. Suitable binders include gum acacia, gelatin, corn starch, gumtragacanth, sodium alginate, carboxymethylcellulose or polyethyleneglycol. Suitable sweeteners include sucrose, lactose, glucose, aspartameor saccharine. Suitable disintegrating agents include corn starch,methylcellulose, polyvinylpyrrolidone, xanthan gum, bentonite, alginicacid or agar. Suitable diluents include lactose, sorbitol, mannitol,dextrose, kaolin, cellulose, calcium carbonate, calcium silicate ordicalcium phosphate. Suitable flavouring agents include peppermint oil,oil of to wintergreen, cherry, orange or raspberry flavouring. Suitablecoating agents include polymers or copolymers of acrylic acid and/ormethacrylic acid and/or their esters, waxes, fatty alcohols, zein,shellac or gluten Suitable preservatives include sodium benzoate,vitamin E, alpha-tocopherol, ascorbic acid, methyl paraben, propylparaben or sodium bisulphite. Suitable lubricants include magnesiumstearate, stearic acid, sodium oleate, sodium chloride or talc. Suitabletime delay agents include glyceryl monoslearate or glyceryl distearate.

Liquid forms for oral administration may contain, in addition to theabove agents, a liquid carrier. Suitable liquid carriers include water,oils such as olive oil, peanut oil, sesame oil, sunflower oil, saffloweroil, arachis oil, coconut oil, liquid paraffin, ethylene glycol,propylene glycol, polyethylene glycol, ethanol, propanol, isopropanol,glycerol, fatty alcohols, triglycerides or mixtures thereof.

Suspensions for oral administration may further include dispersingagents and/or suspending agents. Suitable suspending agents includesodium carboxymethylcellulose, methylcellulose,hydroxypropylmethyl-cellulose, poly-vinyl-pyrrolidone, sodium alginateor ceryl alcohol. Suitable dispersing agents include lecithin,polyoxyechylene esters of fatty acids such as stearic acid,polyoxyethylene sorbitol mono- or di-oleate, -stearate or -laurate,polyoxyethylene sorbitan mono- or-dioleate, -stearate or -laurate andthe like.

The emulsions for oral administration may further include one or moreemulsifying agents. Suitable emulsifying agents include dispersingagents as exemplified above or natural gums such as gum acacia or gumtragacanth.

EXAMPLES Example 1

Treatment of patients with inflammatory bowel disease using acombination of anti-atypical mycobacterial agents

Fifteen patients, aged 13 to 58, were treated with various protocols ofanti-mycobacteria agents. Twelve patients had Crohn's disease and threeulcerative colitis. Presence of Mycobacterium paratuberculosis wasidentified in nine of these patients. A combination of claithromycin(250 mg to 1.5 grams per day), rifabutin (150 mg to 750 mg per day) andclofazimine (3 mg/kg to 10 mg/kg) was used. Rapid clinical remission wasobtained in these patients with cessation of prednisone, azathioprine,and 5ASA compounds and settlement clinically of their inflammatory boweldisease.

After four months of treatment, five patients were examinedcolonoscopically. Two of these patients had normalised the colonic andterminal ileum mucosa while three continued to have patchy inflammatorychanges and histological presence of minimal inflammatory infiltratewith some eosinophils.

In these three patients, a combination of clarithromycin and rifabutin(same dosages as above) together with added clofazimine, 2 mg per kg,made up a preferred therapy. Seventy percent of the patients improveddramatically at 8 months with removal of all need for anti-inflammatorybowel disease medications. No prednisone, azathioprine or 5ASA compoundswere used. The inflammatory process in these patients was no longerdetectable and even histologically no evidence of IBD was present whenviewed under the microscope. However, in one patient who was sensitiveto rifabutin (marked headaches and fever) the rifabutin was changed toethambutol at a dose of 400 mg twice daily. This dose was increased atone stage to 50 mg per kg in an attempt to reverse the inflammatoryprocess and then reduced to 10 mg per kg. The patient also obtainedreversal of the inflammatory process with loss of diarrhoea, loss ofbleeding, and ultimately loss of urgency. In yet a further patient fourdrugs were used simultaneously because of resistance to clarithromycin.Azithromycin, 500 mg each morning (range 250-1,500 mg) was used incombination with rifabutin, clofazimine, and ethambutol.

Example 2

Treatment of patient with inflammatory bowel disease using a microbialextract

A 34 year old patient with two bowel resections and a stricturotomywhile on standard Crohn's disease therapy consisting of azopiathrin,prednisone and mesalazine received an immuno-stimulatory injection ofRegressin. This was given intramuscularly and later orally in a startingdose of 500 μg, followed by 500 μg weekly for four weeks, tand henmonthly.

Two years after recurrent oral immunisation on a weekly and then monthlybasis, the patient remains symptom-free and off all therapy, suggestiveof Crohn's disease reversal and disappearance. At colonoscopy theanastomosis site was free of Crohn's disease.

Example 3

Treatment of Severe Crohn's Disease using Rifabutin-Macrolide-Clofazimine Combination

Patients failing maximal conventional therapy were commencedprospectively on a combination of rifabutin (450 mg/day), clarithromycin(750 mg/day), and clofazimine (2 mg/kg). Azathiaprine was terminatedwhile 5-ASA and steroids were tapered then ceased. Progress wasmonitored by colonoscopy, cross-sectional ultrasound, haematology valuesand the Harvey-Bradshaw activity index. After 8-12 months, 10 patientsachieved near-complete control of Crohn's disease on the combinationtherapy alone. Ileal structures dilated to normal ultrasound wallthickness in all of the five patients examined. Extensive pseudo polypcrops regressed from the colon in the patient suffering from thiscondition, defunctioning ileostomy was closed at 11 months in thepatient suffering from this condition, reversal from inflamed tohistologically uninflamed ileal and colonic mucosa was observed in fiveof twelve patients suffering from this condition. All patients hadessentially normalised haematologic values after 8-12 months oftreatment. In 2 patients, Crohn's disease progressed 2-3 months aftercessation of steroids which were subsequently reintroduced whilecontinuing the combined therapy of the present invention. TheHarvey-Bradshaw index fell from 15.5 to 2.5.

Example 4

Composition for oral administration to patient with inflammatory boweldisease

A composition was prepared containing 150 mg Rifabutin, 250 mgClarithromycin and 50 mg Clofazimine. The composition was presented inthe form of a capsule containing each of the anti-atypical mycobacterialagents in a microencapsulated form.

Example 5

Composition for oral administration to patient with inflammatory boweldisease

A composition was prepared containing 150 mg Rifabutin, 250 mgClarithromycin and 50 mg Clofazimine. The composition was presented inthe form of an inner capsule containing rifabutin, within an outercapsule containing clarithromycin and clofazimine, whereinclarithromycin and clofazimine are present in powdered form.

Example 6

Composition for oral administration to patient with inflammatory boweldisease

A composition was prepared containing 150 mg Rifabutin, 250 mgClarithromycin and 50 mg Clofazimine. The composition was presented inthe form of an inner capsule containing rifabutin, within an outercapsule containing clarithromycin and clofazimine, whereinclarithromycin and clofazimine are present in microgranulated form.

Example 7

Composition for oral administration to patient with inflammatory boweldisease

A composition was prepared containing 150 mg Rifabutin, 250 mgClarithromycin and 50 mg Clofazimine. The composition was presented inthe form of an inner capsule containing rifabutin, within an outercapsule containing clarithromycin and clofazimine, whereinclarithromycin and clofazimine are present in microgranulated form.

INDUSTRIAL APPLICABILITY

The present invention provides a method and composition of medicationsused to treat inflammatory bowel disease. The invention further providescombinations of anti-atypical mycobacterial agents effective against theatypical mycobacterial strains. It also provides a method ofpotentiating the anti-atypical mycobacterial agents in treatment ofinflammatory bowel disease by immunising patients with extracts ofnon-pathogenic mycobactcria.

What is claimed is:
 1. A composition for the treatment of inflammatorybowel disease comprising three or more anti-atypical mycobacterialagents, wherein at least one of said agents is a macrolide.
 2. Thecomposition of claim 1, wherein said anti-atypical mycobacterial agentsare selected from the group consisting of: clarithromycin, rifabutin,rifampicin, azidiromycin, roxithromycin, amikacin, clofazimine,ethambutol, ofloxacin, ciprofloxacin and oxazolidinone.
 3. Thecomposition of claim 1, comprising rifabutin and clarithromycin.
 4. Thecomposition of claim 1, comprising rifabutin, clarithromycin andclofazimine.
 5. The composition of claim 1, further comprising at leastone 5-aminosalicylic acid compound or 4-aminosalicylic acid compound. 6.The composition of claim 5, wherein said 5-aminosalicylic acid compoundor 4-aminosalicylic acid compound is selected from the group consistingof mesalazine, olsalazine, salazopyrin and para-amino salicylic acid. 7.A method for the treatment of inflammatory bowel disease comprisingadministering to a patient in need of said treatment an effective amountof at least three anti-atypical mycobacterial agents, wherein at leastone of said agents is a macrolide.
 8. The method of claim 7 whichadditionally comprises immunizing the patient with a immunizing amountof a mycobacterial extract or product.
 9. The method of claim 7 or 8,wherein said anti-atypical mycobacterial agents are selected from thegroup consisting of: clarithromycin, rifabutin, rifampicin,azithrotnycin, roxithromycin, amikacin, clofazimine, ethambutol,ofloxacin, ciprofloxacin and oxazolidinone.
 10. The method of claim 7 or8, comprising administering to said patient rifabutin andclarithromycin.
 11. The method of claim 7 or 8, comprising administeringto said patient rifabutin, clarithromycin and clofazimine.
 12. Themethod of claim 7 or 8, comprising administering to said patient atleast one 5-aminosalicylic acid compound or 4-aminosalicylic acidcompound.
 13. The method of claim 12, wherein said 5-aminosalicylic acidcompound or 4-aminosalicylic acid compound is selected from the groupconsisting of: mesalazine, olsalazine, salazopyrin and para-aminosalicylic acid.
 14. The method of claim 8, wherein said mycobacterialextract or product comprises an extract or product from non-pathogenicmycobacteria.
 15. The method of claim 14, wherein said non-pathogenicbacteria comprise M vaccae or M phlei.
 16. The method of claim 8,wherein said amount of a mycobacterial extract or product ranges frombetween about 25 μg to about 500 μg.
 17. The method of claim 8, whereinsaid mycobacterial extract or product is administered orally,intravenously, intramuscularly, subcutaneously, or any combinationthereof.
 18. The method of claim 8, wherein said immunizing amount of amycobacterial extract or product is administered from weekly to monthly.19. The method of claim 8, wherein said immunizing amount of amycobacterial extract or product is administered weekly.
 20. The methodof claim 8, wherein said mycobacterial extract or product is Regressin.21. The composition of claim 1, wherein the macrolide is selected fromthe group consisting of clarithromycin, azithromycin and roxithromycin.22. The method of claim 7, wherein the macrolide is selected from thegroup consisting of clarithromycin, azithromycin and roxithromycin.